Updates on NOTICE, Sepsis-3, and hypertensive crisis

Recent actions by CMS have affected multiple topics recently covered in this column,
including communicating with patients about observation status and documenting sepsis
and hypertension.

NOTICE Act

The July Coding Corner explained the Notice of Observation Treatment and Implication for Care Eligibility
(NOTICE) Act, which required that Medicare beneficiaries who receive observation services
for more than 24 hours be given oral explanation and written notification of their
inpatient or observation status within 36 hours of initiation of observation services
or upon release.

On Aug. 2, in the 2017 Inpatient Prospective Payment System final rule, CMS announced
a delay in implementation of the Act. The agency submitted a revised version of the
required notice to beneficiaries, the Medicare Outpatient Observation Notice (MOON),
for public comment before it would receive final approval. The provisions of the NOTICE
Act must be implemented for all Medicare beneficiaries, using the MOON, within 90
days of final approval.

Photo by Thinkstock

In response to already received public comments, CMS has reduced the number of required
fields on the MOON, removing physician name, the date and time observation services
began, and the field for the hospital name. Hospitals will be permitted to preprint
the MOON to include the hospital name and logo at the top. CMS also removed the Quality
Improvement Organization contact section from the MOON due to concerns that it might
unnecessarily prompt a flood of complaints about the nature and quality of care provided.

In response to public comment that the MOON language regarding coverage of posthospital
skilled nursing facility care and Part B coverage should be clearer and more prominent,
CMS has simplified this text and moved it near the top of the notice. In addition,
CMS has added a free-text field where the specific reason for the patient receiving
observation services must be completed by the hospital.

CMS noted that while the Act does not require notice until 24 hours of observation
have been provided, hospitals may voluntarily deliver notice before that deadline
to ensure compliance. CMS does not recommend providing notice when observation services
are initiated, citing concerns that patients may be preoccupied with their health
care needs and other paperwork at that time.

Some states independently require notice of outpatient status for all outpatients,
regardless of the payer and irrespective of whether the patient has received observation
services, and some require notice within 24 hours. CMS notes that, in some cases,
delivering the MOON to Medicare patients under observation may also fulfill state
notice requirements, but hospitals will need to make that determination on a state-by-state
basis.

The revised MOON (Form CMS-10611) and notice instructions can be accessed online.

Sepsis-3

The controversy over the new Sepsis-3 criteria was discussed in the March and June editions of Coding Corner (as well as in the August ACP Hospitalist). discarded the concept of systemic inflammatory response syndrome (SIRS) as the
basis for diagnosing sepsis and eliminated the distinction between sepsis and severe
sepsis.

On July 26, 3 physician representatives of CMS published a letter in JAMA announcing that despite the release of Sepsis-3, CMS will not change the sepsis definitions
in its SEP-1 sepsis management inpatient quality measure. The definitions used in
the SEP-1 measure, which the letter described as “widespread and understood,”
consider sepsis as SIRS due to an infection and severe sepsis as sepsis with acute
organ dysfunction.

CMS pointed out that clinical practice measures require “extensive real-world
field testing to assess reliability, usability, and feasibility” and that “the
SEP-1 measure underwent more than 8 years of development and critical review”
and is supported by a large body of clinical evidence.

While the authors welcomed “new research and innovative thinking,” they
said that “prior to changing the widespread and understood definitions used
in SEP-1, rigorous clinical investigation will be required....”

Other reservations concerning the proposed Sepsis-3 definitions expressed in the letter
included the potential for delayed diagnosis of sepsis, disruption of the current
trend of decreasing sepsis mortality, and negative effects on ongoing quality improvement
efforts.

Along with the CMS response were published other letters expressing concerns about
Sepsis-3, focusing on potential flaws in methods and statistical analysis and the
need for prospective studies to substantiate the real-world clinical validity of the
new Sepsis-3 definitions. The CMS letter promised the agency would track the research
that the new “proposed definitions will inspire.”

Hypertensive crisis

When ICD-10-CM took effect last year, one of the most surprising changes was the elimination
of specificity for hypertension, as discussed in the November 2015 Coding Corner. That has changed with the release of the 2017 Inpatient Prospective Payment System
final rule on Aug. 2.

Codes for the spectrum of hypertensive crisis have been restored. Hypertensive crisis
is a general term intended to encompass both 1) hypertensive urgency with marked elevation
of blood pressure requiring prompt intervention and 2) more serious, potentially life-threatening
hypertensive emergency requiring immediate aggressive intervention.

Hypertensive urgency is characterized by systolic blood pressure (SBP) greater than
180 mm Hg or diastolic blood pressure (DBP) greater than 110 mm Hg with symptoms such
as headache, dyspnea, or chest pain but without end-organ involvement. Hypertensive
emergency is distinguished by SBP greater than 180 mm Hg or DBP greater than 120 mm
Hg with end-organ involvement such as neurologic, renal, or cardiac systems. Obviously,
there can be some gray areas in terms of SBP and end-organ involvement.

In the past, ICD-9-CM had codes for hypertensive crises described by the archaic terms
“malignant” and “accelerated” hypertension. At its launch,
ICD-10-CM inexplicably had no codes to identify this serious condition; all hypertension
other than maternal and that due to heart or kidney disease was assigned to a single
code, I10, having no significant impact on severity.

Thankfully, new codes have been created for these conditions, incorporating current
clinical terminology:

It is not clear why the general, nonspecific term “crisis” is considered
significant while “urgency” is not, even though clinically “urgency”
is included under the term “crisis.” In any case, for proper documentation,
the correct clinical terminology should be used to describe the specific circumstances
encountered with each individual patient. If the patient meets clinical criteria for
hypertensive urgency, but not hypertensive emergency, the condition should not be
described as emergent. Whether to use “urgent” (no severity impact)
or the general term “crisis” (having severity impact) is left to the
clinician's judgement.

Clinicians will have to “unlearn” the terms “malignant”
and “accelerated,” which have been emphasized for proper code assignment
for so many years. These terms should not be used since they are outdated and poorly
defined and have been replaced with current terminology.

Dr. Pinson is a certified coding specialist, author, and cofounder of Pinson and Tang,
LLC in Houston. This content is adapted with permission from Pinson and Tang, LLC. www.pinsonandtang.com

I read the “Sepsis is still confusing” Coding Corner in the FebruaryACP Hospitalistbut am still uncertain about what is required to support a noninfectious SIRS diagnosis.
The case I have in mind is a patient with alcohol-induced pancreatitis who meets none
of those 4 criteria for SIRS. In this case the lactate level was 2.9 mmol/L with acute
kidney injury. Is that noninfectious SIRS?

A: Thank you for this question. As explained in this column in the February 2016 issue,
those 4 SIRS criteria come from the original 1991 sepsis definition published by Bone
et al. in 1992. SIRS criteria were substantially modified and expanded by the 2001
Sepsis Definition Conference published in 2003 and are listed in the first table in
that publication.

These sources do not just define sepsis; they represent the authoritative definitions
of SIRS (2001 being the current one) and then further define sepsis as SIRS due to
confirmed or suspected infection. There are no other authoritative definitions of
SIRS.

While it is ultimately up to the clinician's professional judgment in the particular
situation you describe, the presence of a lactate level of 2.9 mmol/L with acute kidney
injury does seem in my opinion to justify a diagnosis of noninfectious SIRS if the
findings could not be “easily explained by other causes” as required
by the 2001 definition.

Q: My clinical documentation improvement team is curious whether you have encountered
a standard definition or guidance for using the ICD-10-CM code for persistent atrial
fibrillation. It is the only type of atrial fibrillation that represents significant
severity of illness as a secondary diagnosis (a complication or comorbidity for the
MS-DRG). Based on the definitions we have identified, it seems to be very common in
our inpatient population. We would like to code it when it is present but also want
to ensure we are consistent with the medical understanding of the term.

A: How to properly diagnose and code persistent atrial fibrillation has been widely misinterpreted
and is controversial. The accepted clinical definition is atrial fibrillation that
persists for more than 7 days after onset. However, it implies an ongoing or planned
attempt to convert it to sinus rhythm. The designation of persistent atrial fibrillation
is not intended to describe the situation where management will be rate control only
without conversion, thereby allowing it to become a chronic condition.

Got a documentation or coding conundrum? Dr. Pinson answers questions from readers
quickly, and some may be published. Pleasee-mailyour question.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.